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The Purdue Psychology Treatment and Research Clinics (PPTRC) serve the needs of Greater Lafayette and surrounding areas by providing high-quality assessment, therapy and psychoeducational services at affordable prices. The PPTRC is a training clinic for graduate students in the Clinical Psychological Sciences Program of the Department of Psychological Sciences. All services are provided by qualified graduate-level student clinicians who are supervised by licensed psychologists from the Psychological Sciences graduate program. As a training clinic, we have specific requirements and limitations for training our students, which can sometimes mean that we may not be able to take on particular cases or types of problems.

Information you share is held in the strictest confidence. Purdue Psychology Treatment and Research Clinics follow confidentiality guidelines consistent with professional and ethical standards as well as state and federal law. Please note that if the client is over 18 we MUST speak with the client to initiate the screening process.

We strive to create a safe, inclusive and affirming environment for all clients and staff. We hold a deliberately broad conceptualization of multiculturalism and diversity, with an effort to honor all the identities a person may hold, including racial identity, ethnic identity, sexual orientation, gender identity, religious and spiritual beliefs, immigration and acculturation status, ability status, socioeconomic status, military service, and more. Culturally competent care is a cornerstone of our practice and of the clinicians’ training. All clinicians complete a separate course in multicultural education and diversity topics, and many of them are also actively engaged with the Psychological Sciences Diversity, Equity and Inclusion Committee as well as other committees and research projects focused on anti-racism, inclusive practices and prejudice reduction.

We have specific requirements and limitations for training our student clinicians, which can sometimes mean that we may not be able to take on particular cases or types of problems. All incoming clients are reviewed for services on a case-by-case basis using this “Application for Services.”

Specific services we are unable to provide in any circumstances include:
Legal/Court-ordered evaluations or treatment, including (but not limited to) custody evaluations or disability evaluations
Emergency Services: In case of an emergency or if you feel unsafe in any way, call 911 or go to your nearest emergency room.
Same day or walk-in services
Letters for emotional support animals

Please indicate the services you are seeking:

Testing or Assessment Clinic (psychological evaluation; ages 5+)
Adult Services Clinic (adult therapy/treatment; ages 18+)
Adult Services Clinic (ADHD college skills group; ages 18+, enrolled in college)
Child and Family Treatment Clinic (child/teen therapy/treatment; ages 4 - 17)
Child and Family Treatment Clinic (behavioral parent/caregiver training group; ages 5 - 12)

Parent/Caregiver Name (if client is under 18)

Legal Name of Client

Preferred Name of Client (if different from legal name)

Client Age and Date of Birth

Age

Date of Birth

Pronouns

she/her/hers
he/him/his
they/them/theirs
I prefer another option:

Home Address (Number, Street, City, State, Zip Code)

House Number and Street

City

State, Zip Code

Phone

Is it OK to leave a voicemail?

Yes
No

Email Address

Email tends to be the most effective method of contact for our clients and clinicians. Is it OK to email you?

Yes
No

Please describe the concerns that are prompting you to seek treatment:

Are there other significant stressors you or your child are experiencing?

What do you hope to gain from evaluation or treatment?

When did the concerns begin?

Have you (your child) received services for this currently or in the past?

Yes (please describe)
No

These next questions touch on topics of a sensitive nature that do not apply to everyone and so may or may not be relevant to your experience. We need this information to better understand your situation and the kind of service that may be most helpful.

Do you (or your child) currently have thoughts of harming or killing yourself?

Yes (please describe)
No

Do you (or your child) currently have thoughts of death or wishing you were dead?

Yes (please describe)
No

Do you (or your child) have urges to hurt, harm, or kill someone else?

Yes (please describe)
No

Have you (or your child) ever considered suicide or harming someone else?

Yes (please describe)
No

Have you (or your child) ever been hospitalized for emotional or behavioral problems, or suicidal thoughts or attempts?

Yes (please describe)
No

Have you (or your child) ever experienced a problem with alcohol or drug use (including prescription drugs)?

Yes (please describe)
No

Thank you for taking the time to complete this application. As a training clinic we cannot accommodate all requests for treatment and we strive to ensure that the services are the best fit for you and for the training of our student clinicians. Our waitlist times vary by clinic and can be very lengthy (ranging from a few weeks to a year or longer). Your application will be reviewed by our clinic coordinators and they will contact you within 10 business days (excluding university breaks) to complete the screening process and/or to confirm that you have been added to our waitlist for the services you indicated above. If we can meet your needs, you will be added to the waitlist for services and will receive notification, including a list of community resources that may be able to accommodate you more quickly. If we cannot meet your needs, or you would prefer to be seen sooner than our clinic allows, we will provide you with a list of community resources. If we feel that we are unable to provide services that will fit your needs within the confines of our training model we will notify you by email and mail, including referrals for other potential providers.

I understand there are limitations to the types of services the PPTRC can provide
I understand the waitlist times may vary and can be lengthy

My signature below indicates that I agree to apply for services at the PPTRC. I understand that I must complete the screening process prior to engaging in services to determine whether services at the PPTRC are the best fit for my treatment needs and the clinic.

Sign Here

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